Urologists face a significant risk of on-the-job pain and injury, an exclusive 

Ninety percent report experiencing work-related musculoskeletal pain or other discomfort, most commonly in the neck or back, over the course of their career. In what one leading urologist called a “shocking” finding, nearly two-thirds of practicing urologists say they have been threatened by a patient, and about a fourth have suffered a physical attack or abuse at the hands of a patient. (To see the full survey results, read 

"Survey: 90% of urologists experience work-related pain.")

The findings raise questions both about the safety of urologic practice but also effective preventive measures, as just over half of survey respondents say they have “adequate” (44%) or “extensive” (9%) knowledge of surgical ergonomics.

The survey was conducted in late June and July 2019 via email to readers of 

with email addresses on file. It was designed to examine the prevalence and type of physical and psychological harm encountered by U.S. urologists, possible causes, preventive measures, and the perceived need for training in ergonomics. Half of respondents are employed by a hospital/health system (27%) or a private practice with seven or fewer physicians (23%). The majority fall in the 30- to 44-year age range (34%) or 45- to 59-year range (33%). (Also see, "How the survey was conducted," below.)

The concept for the survey was initiated by Stacy Loeb, MD, MSc, a member of the 

 Editorial Council who is assistant professor of urology and population health, New York University Langone and the Manhattan VA, New York.

“There is increasing recognition about physician burnout,” said Dr. Loeb, noting the topic was discussed in a 2019 AUA annual meeting plenary session and featured in the 2018 AUA Update Series. “Less attention has been paid to some of the physical consequences of being a physician.

“Having personally suffered a back injury from lifting a patient, I have spoken to many other urologists about job-related physical issues and wondered why this topic has not received more attention. One recent multinational survey of urologists reported a 45% incidence of spinal pain,” she said, citing a July 17, 2019 paper in the 

 survey, most urologists continued to work despite minor/moderate discomfort (56%) or significant discomfort (29%). Another 5% were able to continue working, but their ability to perform surgery was affected. Two respondents said their pain or discomfort led to early retirement or ended their career.

“Most shocking and concerning of all, 62% of urologist respondents have been threatened and 23% were physically attacked or abused by a patient. Among respondents, 21% were threatened and 8% were physically attacked or abused by another provider,” Dr. Loeb said.

“Many urologists experienced other issues such as needle sticks (75%), dry/cracked skin (58%), and eyestrain (39%) as a result of work activities.”

Twenty percent have been diagnosed with degenerative lumbar spine disease, 17% with degenerative cervical spine disease, 15% with arthritis, and 13% with rotator cuff pathology.

The survey was not designed to determine whether the high prevalence of physical pain/injury is a new phenomenon among urologists, but such occurrences have been common over the last year. When asked how frequently they have experienced work-related musculoskeletal pain or other discomfort in the past 12 months, 32% of respondents said it occurred more than once per week, 21% said it occurred weekly, and 18% said it occurred monthly.

In terms of possible causes of their work-related pain or discomfort, urologists most often cited awkward positioning in the operating room (33%), repetitive movements during surgery (30%), extended periods of standing (15%), and equipment such as a lead apron or loupes (8%).

More than two-thirds (68%) said they took nonsteroidal anti-inflammatory drugs to reduce musculoskeletal strain/injury while performing surgery. Forty-three percent have altered the manner in which they hold instruments, 19% have used mechanical aids to move patients, and 19% have minimized the use of lead aprons.

Only 17% of urologists report receiving training on surgical ergonomics, and 70% would like to receive such training. (Also see, 

“Addressing dangers in the OR starts with education.")

The issues surrounding both the physical and emotional/psychological issues affecting urologists “urgently need to be addressed,” Dr. Loeb said. “To take the best possible care of our patients, we must first take care of ourselves.”

 conducted a survey of readers via email in June and July of 2019 to determine the frequency and type of work-related pain/injury they have experienced. Special thanks to Stacy Loeb, MD, MSc, of the 

Editorial Council, who reviewed and critiqued survey questions developed by the editorial staff. All survey recipients were subscribers to 

, and all were required to report being a urologist or urology resident before responding. A total of 165 responses were received.

Articles

Urologists face a significant risk of on-the-job pain and injury, an exclusive Urology Times survey has found.

Practicing urology takes physical toll

Over the past several years, urologists and men suffering from BPH have been introduced to a growing number of alternatives for managing this disease. In addition to the gold-standard transurethral resection of the prostate (TURP) and the simple prostatectomy (for larger prostates), urologists can now present men with symptomatic bladder outlet obstruction a variety of newer management options including UroLift and Rezum for prostate volumes 30-80 grams. In clinical practice, some urologists are also performing these procedures in men with prostates >80 grams.

Other treatment options include photoselective vaporization of the prostate, holmium laser enucleation of the prostate (HoLEP), and variations of the more conventional treatments, such as the bipolar/button TURP and robot-assisted laparoscopic simple prostatectomy.

Each of these treatments has shared and individual risks and benefits that must be weighed and, of course, compared to the more conservative alternatives when considering “what to do next” in the personalized care of men with BPH requiring or desiring intervention. This article focuses on Aquablation, a newer approach to treatment involving the use of robotically controlled waterjet ablation for prostate tissue removal.

BPH is a prevalent disease affecting approximately 50% of men age 60 years and older and up to 90% of men after the age of 85. Many factors must be weighed when considering the surgical management of BPH, including whether such treatment is necessary or whether more conservative options can be continued or initiated instead. If the decision to pursue surgery is made, the size and shape of the prostate play an important role in selecting the appropriate therapy to not only optimize efficacy but also minimize complications.

Shock wave therapy: ED cure or unproven treatment?

It’s important for patients to know that each individual’s prostate can have a different size and shape. The larger a man’s prostate, the longer it will take the surgeon to resect the obstructive tissue. In terms of shape, while every prostate has two lateral lobes, some men develop an additional median lobe that protrudes into the bladder and increases the complexity of the procedure. Although we know that appropriately removing the obstructive tissue provides patients with BPH effective symptom relief, prostates with increased size and complex shape can lead to suboptimal outcomes, longer operative times, and higher risks during surgery.

Additionally, more and more patients with BPH are asking for less invasive procedures expecting comparable outcomes to the more classic alternatives with less side effects and a more rapid return to their preoperative daily activities.

Over the course of my career, I have predominantly performed bipolar/button TURP, as my practice and referral patterns seemingly led themselves to the management of larger prostates (often with large and complex median lobes) in men with moderate to severe bladder outlet obstruction symptoms. In men with prostates <80 grams, I also perform and discuss the UroLift procedure as an option to consider.

More recently, I have started offering my patients PROCEPT AquaBeam Aquablation of the prostate, which combines robotic technology, multi-dimensional real-time imaging, and a heat-free waterjet to remove obstructive prostate tissue (figure 1). Aquablation therapy provides autonomous tissue removal to safely and effectively treat BPH. It offers predictable and reproducible outcomes independent of prostate anatomy, prostate size, or surgeon experience. The AquaBeam Robotic System is FDA approved.

The Aquablation system enables the urologic surgeon to combine the benefits of traditional cystoscopy (to visualize the anatomy of the prostatic urethra, bladder neck, and bladder) with intraoperative transrectal ultrasound (TRUS) imaging of the prostate. This allows for a multi-dimensional, real-time view of the entire prostate during all aspects of the procedure, enabling improved decision-making and treatment planning.

What do you tell male patients about men’s health clinics?

The procedure begins by developing a personalized treatment plan using multi-dimensional real-time imaging (figures 2a and 2b). The AquaBeam Robotic System then provides an accurate, robotically controlled resection of prostate tissue using a heat-free waterjet (Aquablation), based on the surgeon’s personalized treatment plan for each patient (figure 3).

Data from multiple prospective studies (one of which was a randomized, double-blind study against the gold-standard TURP) have provided a body of clinical evidence demonstrating reproducible outcomes regardless of prostate size. Symptom relief is similar to that of other available resection techniques, while the procedural safety profile is minimized and markedly lower, especially for large, more complex prostates 

 For men concerned about the high risk of sexual side effects, namely postoperative anejaculation associated with the surgical management of BPH, Aquablation therapy has demonstrated strong efficacy outcomes comparable to TURP and a superior safety profile, including a reduction in sexual side effects by a ratio of four to one.

The typical patient is discharged in 1.5 days regardless of prostate size. This length of stay is seen as a benefit of Aquablation for patients with large prostates when compared to those who undergo an open simple prostatectomy, which typically requires a 4- to 5-day hospital stay.

Impact of poor sleep quality on urologic disease

The risk of transfusion across all prostate sizes has been observed to be similar to that of HoLEP and TURP. Following discharge, dysuria is typically less than that seen with traditional BPH surgical options due to the absence of heat for tissue removal.

The WATER (Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue) study is a randomized, double-blind comparison of Aquablation therapy to TURP in 181 men with prostates between 30 and 80 grams. The study demonstrated similar efficacy between the two treatment groups and a shorter mean resection time (4 vs. 27 minutes, 

<.0001), a lower complication rate, and sustained and improved preservation of ejaculation favoring Aquablation 

Severe infertility may dispose males to lower cognitive function

At a follow-up of 2 years, International Prostate Symptom Score (IPSS) improved by 14.7 points in the Aquablation group and 14.9 points in the TURP group 

=.8304, 95% CI for difference: –2.1 to 2.6 points) 

 Two-year improvements in maximum flow rate (Qmax) were large in both the Aquablation and TURP groups at 11.2 and 8.6 cc/sec, respectively 

=.1880, 95% CI for difference: –1.3 to 6.4). Sexual function as assessed by the Male Sexual Health Questionnaire was stable in the Aquablation group and decreased in the TURP group.

Further analysis of the data from the WATER study revealed that Clavien-Dindo grade 1 persistent or grade 2 or higher events occurred in the first 3 months in 20% of Aquablation subjects and 46% of TURP subjects 

<.02). At 180 days, men with a prostate volume >50 mL experienced a statistically significant decrease in IPSS of 17.4 points with Aquablation versus 13.3 points in men who underwent TURP 

=.02). Compared with TURP, the WATER study also demonstrated a greater reduction in IPSS with Aquablation in men with a low baseline flow rate <9 mL/s (17.9 vs. 14.3, respectively, 

=.03), greater reduction in IPSS in men with median lobe (19.9 vs. 11, respectively, 

=.005), and a seven-point greater reduction in IPSS in men with both larger prostate and lower baseline flow rate, <9 mL/s 

From the surgeon’s perspective, a major advantage of this procedure in my opinion is the short learning curve and reproducibility of technique from one case to another. During each procedure, the urologic surgeon follows the same planning steps. Once satisfied with the individualized treatment plan, the robot will execute the precise Aquablation in approximately 5 minutes or less regardless of prostate size or shape. Patients’ concerns regarding an autonomous robot can be easily calmed, as the urologic surgeon monitors every aspect of the procedure and is able to instantly stop the procedure at any time by simply lifting his or her foot off the activation pedal.

Another advantage of Aquablation is the ability to perform this technique on any prostate regardless of size, thus allowing an option for men with larger prostates for whom the only alternative is often the more invasive simple prostatectomy. The single-arm WATER II study looked at 12-month safety and efficacy outcomes of the Aquablation procedure for the treatment of men with symptomatic BPH and large-volume prostates (mean prostate volume, 107 cc; range, 80-150 cc) 

 Mean operative time was 37 minutes, and mean Aquablation resection time was 8 minutes. Average length of hospital stay following the procedure was 1.6 days.

Mean IPSS improved from 23.2 at baseline to 6.2 at 12 months 

<.0001). Mean IPSS quality of life improved from 4.6 at baseline to 1.3 at 12-month follow-up 

<.0001). Significant improvements were seen in Qmax (12-month improvement of 12.5 cc/sec) and post-void residual (decrease of 171 cc in those with PVR >100 at baseline). Antegrade ejaculation was maintained in 81% of sexually active men. No patient underwent a repeat procedure for BPH symptoms. WATER II demonstrated that Aquablation is a safe and effective surgical alternative for men with large prostate glands, with durable outcomes at 1 year, fast operative times, short hospitalizations, maintenance of antegrade ejaculatory function, and no significant increase in procedure or resection time compared to smaller sized glands.

To date, our team has performed 40 Aquablation procedures with maximum prostate size of 201 cc (32 to 201 cc). Of the 40 patients who underwent Aquablation, 29 had prostates larger than 80 cc, 15 greater than 100 cc, and three greater than 150 cc. Thirty-three of the 40 men had prostates with a median lobe, 37 had severe obstruction on urodynamic evaluation, and 19 men suffered from urinary retention, 13 of whom required catheterization. Average change in IPSS following Aquablation was 15.5 (range, 6-26) with average preoperative IPSS of 21.7 (range, 10-33) versus 6.6 postoperatively (range, 1-15).

Although we are still awaiting postoperative uroflow studies on all patients, several patients have registered postoperative flow rates greater than 40 mL/s. Additionally, all of the men with preoperative urinary retention are able to void spontaneously, completely, and without need for catheterization. Of those with catheter dependence preoperatively, all can void spontaneously, with bladder scan results demonstrating complete emptying.

Aquablation has a short learning curve, and the planning strategy and technique can be easily reproduced regardless of the prostate size or shape. Initial published data have demonstrated very strong efficacy outcomes comparable to TURP and simple prostatectomy with a superior safety profile, including a reduction in sexual side effects regardless of prostate size. One-year follow-up data confirmed a sustained reduced rate of sexual side effects, durability in symptom reduction, improved flow rates, and a very low rate of re-treatment.

In prostates larger than 50 cc, the Centers for Medicare & Medicaid Services found Aquablation therapy to represent a “substantial clinical improvement” to both TURP and simple prostatectomy. The AUA recently joined the Canadian Urological Association in adding Aquablation therapy to treatment guidelines for men suffering from LUTS due to BPH. The benefit of Aquablation’s minimal invasiveness is especially true for men with very large prostates for whom the simple prostatectomy had previously been among the few options to consider.

is a fellowship-trained minimally invasive urologic surgeon who practices with his father, Ahmad Kasraeian, MD, at Kasraeian Urology in Jacksonville, FL. Dr. Ali Kasraeian serves as a proctor for PROCEPT BioRobotics.

 is assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City, and 

 is professor of urology, Icahn School of Medicine at Mount Sinai, New York.

The treatment provides an alternative to simple prostatectomy in men with large prostates.

Waterjet ablation offers minimally invasive option for BPH

Dr. Rosevear is a urologist in community practice in Colorado Springs, CO. Urology Times blogs present opinions, advice, and news from urologists and other urology professionals. Opinions expressed by bloggers are their own, and do not necessarily reflect the views of Urology Times or its parent company, MJH Life Sciences.

It started as a tightening of my lower back, sort of a twinge. I had been helping move a patient from the transport bed to the operating room bed. It was something I’ve done countless times. I reached over the operating room table to pull the patient over that incredibly firm and uncomfortable roller board we use when it happened. I didn’t think much of it at the time, finished the case, and went about my normal day.

Survey: 90% of urologists experience work-related pain

By that night, my back hurt and by the following day (thankfully a Saturday), I couldn’t even stand up straight. I tried anti-inflammatories and even borrowed my wife’s TENS unit. By Monday, while I was in no shape to do anything terribly physical, I was on the mend.

I was lucky. According to the World Health Organization, the lifetime prevalence of significant back pain is 70% with a 5% per year incidence. The incidence of this injury peaks between the ages of 35 and 55. Further, low back pain is the number one cause of activity limitation and work absence, 

 Back injuries are real and not easy to fix.

Consider all of the maneuvers we do in the operating room: awkward positions, lifting objects above the waist, standing in one position for long periods of time, rotating the torso while bearing weight, wearing heavy lead, adding weight to our neck in the form of loupes or operating lights, pulling patients up in a bed, or as in my case, repositioning a patient.

 looked at the prevalence of work-related musculoskeletal disorders and found that the incidence of these injuries was much higher in surgeons than in other physicians. The authors found that among surgeons, the risk of degenerative cervical disease and degenerative lumbar disease was 17% and 19%, respectively. Rotator cuff pathology and carpal tunnel syndrome were also abnormally high at 18% and 9%, respectively.

These injuries resulted in 12% of surgeons requiring a leave of absence or a practice modification. These are incredibly high numbers.

What can you do? Protect yourself. All surgeons need to be educated on the dangers associated with what we do. Proper technique when moving patients, including the use of mechanical aids, is vital. Minimizing the use of lead gowns with judicial use of radiation cannot be understated. Exercising to strengthen your core and maximize internal support has been shown to decrease the risk of low back disease.

This education needs to happen before the injury and should likely start at the resident or even medical school level. If you wait until your back hurts, you’ve waited too long.

But it’s worse than you think. As surgeons, not only do we expose ourselves to musculoskeletal disorders, we face additional personal risks we need to monitor and mitigate. Take needle sticks, for example. While most surgeons are vaccinated against hepatitis B, as we know, there are no vaccines available for numerous other pathogens such as hepatitis C and HIV. It has also been shown that surgeons tend to have poor compliance with universal precaution procedures 

Worse, we tend to be poorly complaint with reporting our injuries. Simple maneuvers such as double gloving can significantly reduce the risk of disease transmission from exposure, an 

 explains. As we all know, the problem with double gloving is the change in tactile sensation. However, studies have shown that this change, while real, can be overcome with time and training 

 Again, education is key and while it may be challenging to convince the current cohort of surgeons to change their gloves, there is no reason why all residents shouldn’t be trained to use double gloves.

There is more to skin protection than simply wearing gloves. Frequent scrubbing and other hand hygiene tends to dry out skin, and that problem is made worse by prolonged periods of occlusion from gloves. Why is that a problem? It can lead to dry, cracked skin, which increases the risk of pathogen transmission. Routine use of a moisturizer should be considered; if your operating room doesn’t offer access to one, ask. When you consider moisturizer use as a way to protect yourself against bloodborne pathogens, even the toughest of surgeons may start using it.

But wait, there’s more. Intraoperative imaging is key to safely performing many of the procedures we do. Unfortunately, as Marie Curie learned many years ago, uncontrolled exposure to radiation can have detrimental effects. We all know common techniques to reduce exposure such as distance, shielding, and dose reduction, but how much risk is there? A recent study that prospectively measured radiation exposure during more than 100 common urologic procedures found that surgeons’ exposure during any one case was less than 1/100

 While that is good news, for those of us who tend to do a lot of fluoroscopy-intense procedures, individual doses can add up over years.

No one is advocating that we stop operating, and some of the risks discussed here cannot be modified. But steps are available to minimize these risks, and education regarding the dangers we face on a daily basis is the first step to preventing the problem.

Injury stemming from awkward maneuvers and equipment can and should be prevented, says Henry Rosevear, MD.

Addressing dangers in the OR starts with education

Results of a phase III trial show the benefit of darolutamide (Nubeqa) in reducing the risk of metastases or death compared with placebo in men with nonmetastatic castration-resistant prostate cancer (nmCRPC). The FDA recently announced approval of the novel nonsteroidal androgen receptor (AR) antagonist for the treatment of this patient population.

Study data presented at the American Society of Clinical Oncology annual meeting in Chicgo show that men treated with darolutamide maintain quality of life and benefit with delays in worsening of pain and time to symptomatic skeletal events.

The research was presented by Karim Fizazi, MD, PhD, head of cancer medicine, Institut Gustave Roussy, and professor of oncology, University of Paris-Sud, Villejuif, France.

Prostate cancer imaging agent detects regional/distant metastases

“Recently, two AR antagonists, namely apalutamide [Erleada] and enzalutamide [XTANDI], demonstrated improvements in metastasis-free survival (MFS) in men with nmCRPC. However, they are associated with side effects, including fatigue, falls, and mental impairment, which may be related to their ability to cross the blood-brain barrier. Because most men with nmCRPC are asymptomatic, a major therapeutic objective is to prevent cancer progression while avoiding side effects and preserving quality of life,” Dr. Fizazi said.

“The [current] results show that darolutamide significantly improves MFS, has a very favorable safety profile with apparently no side effects associated with other AR antagonists, and delays worsening of pain and disease-related symptoms compared with placebo. This efficacy and safety profile could make darolutamide an attractive treatment option for men with nmCRPC.”

Known as ARAMIS, the phase III study investigating darolutamide included 1,509 men with nmCRPC who had a rapidly rising PSA, defined as a doubling time ≤10 months, and ECOG status 0 or 1. They were randomized 2:1 to treatment with darolutamide, 600 mg twice daily, or placebo. All patients continued on androgen deprivation therapy. The two study groups were well balanced in their baseline characteristics.

Metastasis-free survival was analyzed as the primary endpoint, and the results showed a 59% risk reduction (

<.0001). Median MFS was 18 months for the darolutamide group versus 14 months for the controls.

In an immature interim analysis, the 3-year overall survival rate was 83% for darolutamide and 73% for the control group (29% risk reduction; 

=.0452). Median time to PSA progression was also significantly delayed by darolutamide treatment compared to placebo (median, 33.2 vs. 7.3 months; 

“I would like to emphasize how rising PSA can be associated with patients’ anxiety,” Dr. Fizazi said.

Time to pain progression delayed by 15 months

Median time to pain progression, defined as an increase of ≥2 from baseline on the Brief Pain Inventory-Short Form or start of opioids, was delayed by 15 months with darolutamide (

<.0001). Analysis of the impact of darolutamide on symptomatic skeletal events was still immature due to a low number of events, but the available data showed a 57% reduction with darolutamide (

Data on quality of life collected with the FACT-P Prostate Cancer Subscale questionnaire showed mean scores were unchanged in both treatment groups throughout the available follow-up. Median time to deterioration, defined as a ≥3.0-point decline from baseline, was approximately 11 months in the darolutamide group and 8 months in the control group (

A post-hoc analysis of data from subscales of the EORTC Quality of Life-PR25 questionnaire showed darolutamide treatment was associated with significant delays in deterioration of bowel symptoms and urinary symptoms, and there was a trend for a benefit in delaying deterioration of sexual activity. There were no differences between study groups in time to deterioration of hormonal treatment-related symptoms or incontinence.

Novel US ablation therapy shows significant PSA effect

After adjustment for duration of treatment exposure, the incidence of all adverse events associated with AR antagonists was similar in the darolutamide and placebo groups.

Prior to Dr. Fizazi’s presentation, Neal D. Shore, MD, presented a separate paper also containing data from ARAMIS at the AUA annual meeting in Chicago. Among the findings Dr. Shore presented was that darolutamide delayed time to subsequent antineoplastic therapies compared with placebo.

“It would appear that this is a very attractive option for patients with nmCRPC,” said Dr. Shore, director of Carolina Urologic Research Center, Myrtle Beach, SC.

Dr. Fizazi is a consultant/adviser for Amgen, Astellas Pharma, AstraZeneca, Bayer, Clovis Oncology, Curevac, ESSA, Janssen Oncology, Orion Pharma GmbH, Roche/Genentech, and Sanofi. For full disclosures from the study Dr. Fizazi presented, see 

. Dr. Shore is a consultant/adviser for Amgen, AstraZeneca, Bayer, Dendreon, Ferring, Genentech/Roche, Janssen Scientific Affairs, Medivation/Astellas, Myovant Sciences, and Tolmar. 

Results of a phase III trial show the benefit of darolutamide (Nubeqa) in reducing the risk of metastases or death compared with placebo in men with nonmetastatic castration-resistant prostate cancer.

Novel nonsteroidal AR antagonist shows benefit in treating nmCRPC

I’m getting married soon. What financial items should I consider when tying the knot?

The marriage process, regardless of age, requires careful thought about a number of financial situations a couple will likely face. With financial disagreements being a leading cause of marital problems, why not tackle them ahead of time? This may include reaching out to your financial planner and other legal and tax advisers well in advance of the nuptials.

The starting point is to have a candid discussion with your fiancÃ© about your overall finances. For example, how much debt is each of you bringing to the marriage? What about savings? The older you are, the more (good and bad) financial baggage you’re likely to bring to the partnership.

Avoid these six mistakes that can hinder your financial goals

Next, from a savings standpoint, you’ll need to decide if you will be combining accounts or keeping them separate. Your financial adviser can walk you through what will be needed to combine checking, savings, and money market accounts. He or she can also advise you about adding or changing beneficiaries on your individual retirement accounts and other retirement plans.

Even if you decide to maintain separate accounts, it may be helpful to have at least one joint account to pay for shared expenses, such as mortgage or car payments, rent, household expenses, and insurance premiums. This account is meant strictly for household needs, and it allows you both to keep track of how you are spending money.

A joint account can also help avoid complications in the event one spouse dies. When a spouse or common law partner dies and there are separate accounts, the survivor will be excluded from the other separate account if the estate goes into probate. That could take months and add additional expenses due to court and attorney fees.

"If you are both employed, you must take time to review and coordinate your employee benefits"

If you are both employed, you must take time to review and coordinate your employee benefits. You might save money by eliminating duplicate health care, for example. This process also allows you to determine and then make any changes to the beneficiary designations on retirement plans and insurance policies held through your employers.

Next, sit down and identify financial goals as a couple. Start by creating an annual budget, as well as a contingency plan in case a spouse gets laid off or becomes disabled. Make sure you have an emergency cash reserve. Designate who will be responsible for paying the bills and keeping you on budget. Also look beyond your current financial situation. For example, discuss what you envision your retirement will look like and whether current retirement account contributions are sufficient to achieve your long-term goals.

People who have been previously married may bring additional financial issues to the table, especially if they have children or are required to pay alimony, child support, or insurance premiums under the terms of a divorce settlement agreement. Also consider whether your remarriage will nullify any entitlements to assets from a former spouse. Meet with your advisers to address these issues whenever you are considering blending your finances.

How to assemble your financial professional network

Remember that whether it’s your first time down the aisle or not, marriage is a celebration. Don’t let all of the financial and administrative details that go along with your special day spoil it. Meet with your financial, tax, and legal advisers to establish a budget and tackle other financial and legal issues head-on. A little planning on the front end can alleviate stress well beyond the wedding day.

What estate planning items should be considered when getting married?

Marriage is a good time to meet with an estate planning attorney and get a plan in place. Estate planning is often pushed aside because it deals with a conversation most couples don’t like having-“What happens if one of us dies?” However, it is important to have a plan in place.

A will may be a good first step, but may not be necessary depending on the assets that are owned. An estate planning attorney will be able to provide specific guidance. Having health care and durable power of attorneys in place is always smart in the event you are incapacitated. Depending on your assets, certain trusts may also play an important role in accomplishing your estate planning goals.

The information in this column is designed to be authoritative. The publisher is not engaged in rendering legal, investment, or tax advice.

Work out decisions on combined accounts and long-term goals before the big day, advises Jeff Witz, CFP.

Vol. 47 No. 8

Practicing urology takes physical toll

Waterjet ablation offers minimally invasive option for BPH

Addressing dangers in the OR starts with education

Novel nonsteroidal AR antagonist shows benefit in treating nmCRPC

When getting married, don’t forget financial planning